Ambulatory Care Pulmonary embolism pathway

2019/2020 Suspected PE in Non cancer and Non pregnant patients

Emergency Department or Medical team Initial Assessment: Two-Level PE score (see next FBC, U&E. LFT, Coagulation screening, CRP, ECG, Chest X-Ray sheet for scoring) Clinical S&S of DVT An alternative diagnosis is less Consider urgent CTPA/Echo likely and thrombolysis if: systolic No Patient Heart rate >100 beats per min Immobilaisation for more than 3 BP<90 Marked hypoxemia stable? days or surgery in previous 4wks Previous DVT/PE Yes Haemoptysis Assess clinical probability using TWO-LEVEL PE WELLS scoring Malignancy 1. Is another diagnosis unlikely (chest radiograph and ECG are helpful)? PE Likely – more than 4 points Score: 4 or less – PE unlikely PE unlikely 4 points or less 2. Is there a major risk factor? - see PE Wells list Score: more than 4 points – PE likely Well’s> 4 Well’s ≤ 4 Intermediate/low: Test D-Dimer and take any other NOT TO BE diagnostics check blood results taken on USED IN admission High: No D-Dimer PREGNANT PATIENTS

Positive D-dimer age adjusted Negative D-dimer age adjusted

Investigations: book CTPA/VQ immediately via ACC N.B Radiologist can make decision as to CTPA/ VQ based on Consider assessment alternative If female – assess pregnancy status (Last normal menstrual diagnosis period/Urine Dip) and order investigations accordingly

sPESI ≥ 1 Assess management in OPD setting against sPESI score Not suitable for Consider further In non pregnant Outpatient NOT TO BE investigations patients Management USED IN for cancer with an PREGNANT abdo-pelvic CT scan sPESI 0 PATIENTS (and a mammogram for women) Start Tinzaparin according to dosing table if in all patients aged over 40yrs immediate CTPA not available. Prescription with a 1st unprovoked DVT record sheet signed essential for teams or PE who do not have giving tinzaparin Arrange for pt to signs/symptoms of cancer return to Ambulatory based on initial care for daily Community injections OR refer to investigation Relative or patients able to administration service No H@H administer Tinzaparin? No available? Patient must be housebound Yes Yes If CTPA positive for PE refer Make referral to Rapid to ANTICOAGULATION Instruct patient or relative Response or CLINIC on giving tinzaparin, Community Nurses provide sharp box If CTPA negative, consider a proximal leg vein scan if CTPA Results DVT is suspected. If negative and no other ALL patients referred from ED MUST be seen in ACC for medical review prior to anticoagulation clinic referral concerns discharge; if positive move to DVT pathway SOURCE: Adapted from an example from NHS Institute for Innovation and Improvement website (www.institute.nhs.uk) and Kaiser Permanente Guidelines1 2019/2020 TWO-LEVEL Pulmonary Embolism PE WELLS SCORE ( NOT VALIDATED IN PREGNANCY)

Clinical Feature Points Clinical signs and symptoms of DVT (minimum of leg swelling 3 and pain with palpitation of the deep veins) An alternative diagnosis is less likely than PE 3 Heart rate > 100 beats per minute 1.5 Immobilisation for more than 3 days or surgery in past 4 weeks 1.5 Previous DVT/PE 1.5 Haemoptysis 1 Malignancy (on treatment, treated in last 6 months or palliative) 1

Clinical probability simplified scores PE Likely More than 4 points PE unlikely 4 points or less Adapted with permission from Wells PS et al. (2000)

*VQ Scan indications ( available Monday and Thursdays only ) •Pregnant/ Breastfeeding •Young patient •Normal CXR •Deranged Renal function

4 2019/2020 Assessment of suitability for ACC Management using PulmonaryPE Treatm eEmbolismnt: Choice o Severityf Setting Index (PESI) and Inpatient setting Outpatient setting Simplified• All pregnant women Pulmonary EmbolismIncluding Index short-stay (sPESI) observation unit , where available. • All patients not meeting ACCP criteria • Patients meeting ACCP criteria and electing • Patients( NOT electing VALIDATED inpatient treatment via shared IN PREGNANCY)outpatient treatment via shared decision making decision making

Pregnant women All pregnant women with confirmed acute PE should be treated in an inpatient setting. Non-pregnant adults (with or without cancer) KPWA recommends using the American College of Chest Physicians (ACCP) criteria below to determine which patients with confirmed acute PE are suitable for outpatient treatment and can be safely discharged from urgent care to home. (Note: For clinics with short-stay observation units, an additional option is to discharge patients to that unit for shared decision making around choice of treatment setting.) ACCP criteria for outpatient treatment of acute PE • Patient is clinically stable with good cardiopulmonary reserve. • Patient has no contraindications, such as recent bleeding, severe renal or liver disease, or severe thrombocytopenia (< 70,000/mm3). • Patient has none of the following: right ventricular dysfunction shown on echocardiogram, or signs of right heart strain on CTPA, or increased cardiac biomarkers (troponin or brain natriuretic peptide) levels. • Patient is expected to be compliant with treatment. • Patient feels well enough to be treated at home. • Patient has a Pulmonary Embolism Severity Index (PESI) score of < 85:

Pulmonary Embolism Severity Index (PESI) The PESI is a validated, accurate, easy-to-use tool that can be used at no cost. It can be accessed at http://www.mdcalc.com/pulmonary-embolism-severity-index-pesi/ Predictor Points Age +1 per year Male sex +10 Heart failure +10 Chronic lung disease +10 Arterial oxygen saturation < 90% +20 +20 +20 Temperature < 36° C/96.8° F +20 Cancer +30 Systolic blood pressure < 100 mm Hg +30 Altered mental status +60 3

Risk classification based on PESI score Risk PESI 30-day Recommendation score mortality Class I: Very low risk < 65 0.1 to 1.6% Offer outpatient treatment to Class II: Low risk 66–85 1.7 to 3.5% patients in Classes I and II. Discuss the benefits and risks of outpatient treatment. Class III: Intermediate risk 86–105 3.2 to 7.1% Provide inpatient treatment for Class IV: High risk 106–125 4.0 to 11.4% patients in Classes III–V. Class V: Very high risk > 125 10.0 to 24.5%

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SOURCE: Adapted from an example from NHS Institute for Innovation and Improvement website (www.institute.nhs.uk) and Kaiser Permanente Guidelines 2017 2019 Suspected PE evaluation and diagnosis in Pregnant PE Evaluation and Diagnosis: Pregnant Women This algorithm is based on Leung 2012. Woman

Outpatient with suspected pulmonary embolism, based on symptoms

Clinically WELL’s SCORE is YES CT pulmonary angiography unstable? not validated in Pregnancy

NO

Leg YES symptoms?

Bilateral lower limb POSITIVE Doppler ultrasound

NO NEGATIVE

ChestChest X X--rayray Treat for pulmonary andand embolism as inpatient. CT pulmonaryVQ Scan angiography

BOTH NEGATIVE EITHER POSITIVE

If pulmonary embolismTreat, treatfor PE for PE as inpatient. PE unlikely. Consider other diagnoses. • Start/ContinueIf other diagnosis LMWH ( e.g., pneumonia, 4 pneumothorax, CHF), treat accordingly.

• Refer to Antenatal Clinic – ANC reception contact ext 7017 to book patient in

• See trust wide guidance on VTE in pregnancy

Adapted from Leong 2012 and Kaiser Permanente Guidelines 2017 2019/2020

4 Suspected PE evaluation and diagnosis in Adults with PE Evaluation and Diagnosis: Adults with Cancer cancer This algorithm is based on NCCN 2016.

Outpatient with suspected pulmonary embolism, based on symptoms

Wells Criteria Estimate clinical pretest probability of PE : • Clinical signs 3 Wells Criteria • Alternative diagnosis unlikely 3 • Heart rate >100 bpm 1.5 • Immobilization previous 4 days 1.5 Wells score • Previous DVT/PE 1.5 Wells score • Hemoptysis 1 ≤≤ 4 4 > ≤4 5 • Malignancy (treatment in last 6 months) 1 ≤ 4 Chest X-ray PE less likely: ≤ 4 PE likely: > 4 and > 4 Age-adjusted D-dimer

Age-adjusted D-dimer 50, cutoff = 500 ng/mL For age > 50, cutoff = [age in years] X 10 ng/mL

Diagnostic for other condition • DetermineDetermine treatment if adequate setting for CT pulmonary (e.g., pneumonia, NO POSITIVE OPDand treatsetting. for pulmonary angiography pneumothorax, • Start /Continueembolism LMWH. CHF)? • Inform Oncology team via Yellow Board • Oncology team to decide NEGATIVE on duration of YES anticoagulation

PE unlikely. Consider Treat accordingly. other diagnoses.

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Adapted from Kaiser Permanente Guidelines 2017 2019/2020

5 Investigation for cancer in unprovoked DVT/PE

Unprovoked PE/DVT > 40 years of age or suspicious history +/-examination

• CT- TAP – Order urgent OPD • Woman - Mammogram via GP • Men - PSA via GP

Normal scan Cancer or possible cancer diagnosis Consultant to write to patient with results • Patient to be re-yellow boarded to ACC • Results to be discussed with patient in person • Referrals to MDT and Oncology team made via 6 ACC team • If on NOAC or Warfarin to switch to Tinzaparin • Oncology to review duration of anticoagulation

2019/2020 Tinzaparin Dosage Calculation tool for the treatment of DVT and PE Subcutaneous Low Molecular Weight Heparin (LMWH)

•The patient MUST be weighed before prescribing tinzaparin. •The weight MUST also be documented on the patient’s inpatient prescription chart. •The treatment dose of tinzaparin given subcutaneously is 175 units/kg ONCE a day •Doses must be rounded to the nearest 1000 units (0.05ml) so that the dose is measurable. •The patient’s actual weight should be rounded to the nearest 5kg.

For further information please contact Medicines Information (MI) on extension 7114

NOTES: For patients that weigh more than 130kg actual body weight should still be used to calculate the dose. For such patients monitoring of anti-factor Xa should be considered. Monitoring of anti-factor Xa activity should be considered in patients with severe renal impairment (creatinine clearance (CrCl) < 30 ml/min)1 For patients with a CrCl of <20ml/min use an alternative treatment (e.g. enoxaparin 1mg/kg OD2). Please seek further advice from the ward pharmacist or Medicines Information. Each pre-filled syringe and multidose vial contain tinzaparin at a concentration of 20,000units/ml.

1.Summary of Product Characteristics (SPC) for Innohep (tinzaparin) last updated on the eMC: 02/12/2010 2.The Renal Drug Handbook, 3rd Edition, 2009 Adapted from a document from Imperial College NHS Trust by Nadine Hall on behalf of the Department of Pharmacy Luton and Dunstable Hospital. Approved by The Drug & Therapeutics Committee September 2011. Review date September 2013

3 2019/2020 PULMONARY EMBOLISM AMBULATORY CARE - EAU / IMAGING PATHWAY

A&E/ EAU decides patient meets criteria for Ambulatory care and CTPA/VQ* required

•Dr requests CTPA/VQ *on ICE •Dr sends yellow board to ACC

•Location “ambulatory care” will trigger apt within 48hrs Mon – Fri •Ensure patient’s contact number is on request •If female – assess pregnancy status- (LNMP/Urine dipstix)

•ACC team receives referral •ACC team rings Radiology for date & time of scan •ACC team to inform patient of time and date of scan telephonically

IF REQUESTS are MADE BETWEEN 4.30PM FRIDAY, SATURDAY,SUNDAY AND BANKHOLIDAYS (until further notice) ACC team will ring Radiology the next working day

•Patient arrives 30 minutes before scan appointment •ACC team- inserts IVI cannula •Patient returns to ACC after imaging to be seen by doctor for results

5 2019/2020 REFERRAL TO ANTICOAGULATION SERVICE

PE confirmed

Continue Tinzaparin

Refer to Anticoagulation service for discussion of ongoing anticoagulation

Ambulatory Care to Anticoagulation clinic staff referrals roles

Doctor roles

*Complete written clinic notes *Check baseline bloods *Complete Inpatient prescription sheet for S/C LMWH *Refer on ICE (or FAX 7568 as contingency plan) The anticoagulation nurse led clinic cannot see a patient if this pathway has not been completed.

Ward/clinic clerk roles

*Phone the anticoagulant clinic (ext 7537) between 9am-3pm for an appointment date and time *Confirm the patient can attend clinic, book Transport if necessary *Provide patient with Patient transfer information letter from Ambulatory Care to Anticoagulation clinic with written appointment details completed if known *Place completed notes in Anticoagulation tray in Emergency Assessment Unit clerk office; these will be collected by the anticoagulation admin staff by 9am the next working day. *On Bank Holidays and Weekends the patient will need to attend Ambulatory care for ongoing treatment. 9

2019/2020

Patient Transfer Information from Ambulatory Care to Anticoagulation clinic

Anticoagulation Clinic Service Hours are Monday to Friday 9.30am – 12 noon we are not open at weekends or bank holidays.

Dear Patient

You have been referred to the Anticoagulant clinic for treatment of Venous Thromboembolism E.g. Deep vein thrombosis (blood clot in your leg). Or Pulmonary Embolism (blood clot in your lung).

Your clinic appointment details are

DATE………………… TIME………………….

If you have not been given an appointment, the anticoagulation clinic will contact you the next working day. If you have not been contacted by 09.30am. Please phone the anticoagulation clinic on 01582 497537 as soon as possible

The anticoagulation clinic is located on the first floor of the main hospital building, In Zone B in the out patients department.

If you require hospital transport please discuss with the discharging ward. 10 Please bring your current medication to the appointment, including any self-prescribed medicine.

Please inform the clinic nurse of any allergies.

Thank you

2019/2020 References

• British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE) - 2018 Luke S G E Howard,1 Steven Barden,2 Robin Condliffe,3 Vincent Connolly,4 Christopher W H Davies,5 James Donaldson,6 Bernard Everett,7 Catherine Free,8 Daniel Horner,9,10 Laura Hunter,11 Jasvinder Kaler,12 Catherine Nelson- Piercy,13 Emma O’Dowd,14 Raj Patel,15 Wendy Preston,16 Karen Sheares,17 Campbell Tait18

• Leung AN, Bull TM, Jaeschke R, et al; ATS/STR Committee on Pulmonary Embolism in Pregnancy. American Thoracic Society documents: an official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline—Evaluation of Suspected Pulmonary Embolism in Pregnancy. Radiology. 2012 Feb; 262(2):635-646.

• Kaiser Permanente Guidelines on Pulmonary embolism diagnosis and treatment – October 2017

• NICE Clinical Guideline [CG144] Venous thromboembolic diseases: diagnosis, management and thrombophilia testingPublished date: June 2012 Last updated: November 2015

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2019/2020